All Reports

Executive leaders ensure there are clear signs during construction projects, and maps at the main entrance information desk to help veterans navigate the facility.

The Medical Center Director ensures contractors inspect and test emergency generators and fire doors as required, and staff report compliance to an environment of care committee.

The Medical Center Director ensures an environment of care committee meets, as required.

The Associate Director of Patient Care Services/Nurse Executive ensures nursing staff monitor proper food clean-up, storage, and disposal in the Mental Health Residential Rehabilitation Treatment Program’s areas.

The Medical Center Director ensures staff refill hands-free sanitizer dispensers throughout the facility.

The Medical Center Director ensures the emergency management plan includes guidance for managing shelter-in-place supplies.

Executive leaders ensure staff develop service-level workflows for the communication of test results for each service.

The Medical Center Director ensures staff implement a process to monitor providers’ compliance with communicating abnormal test results to patients.

Executive leaders ensure staff complete improvement actions from root cause analyses within one year.

The Under Secretary for Health ensures that VA homeless program staff consistently document, in patients’ electronic health records, the clinical information from the Homeless Operations Management and Evaluation System.

The Under Secretary for Health makes certain that a suicide risk screening is completed with patients during intake into VA homeless programs, consistent with Veterans Health Administration policy.

The Under Secretary for Health ensures that staff complete suicide risk screening in response to danger of self-harm identified in the Homeless Operations Management and Evaluation System.

The Under Secretary for Health makes certain that homeless program staff provide and document care coordination to address patients’ mental health and substance use disorder treatment needs as identified in the Homeless Operations Management and Evaluation System.

Facility leaders ensure providers who order tests communicate the results to patients timely.

Ensure the Palo Alto major construction project (project number 640-424) is brought into the Acquisition Program Management Framework.

Ensure the activities and artifacts required during the verify phase of the Acquisition Program Management Framework are completed for the Palo Alto major construction project (project number 640-424)—including a business case with cost, schedule, and performance goals approved by the Secretary.

Ensure a decision event to verify the need of the acquisition is conducted for the Palo Alto major construction project (project number 640-424) and a determination is made to terminate or continue this project based on VA’s strategic needs and the VA Palo Alto Health Care System’s clinical needs.

Ensure VA’s FY 2025 Agency Capital Plan is revised to show the Palo Alto major construction project’s current total estimated cost and the progress the project has made toward meeting its critical objectives.

Ensure processes and guidance are in place for the director of the Office of Construction and Facilities Management to provide appropriate oversight and management over minor construction projects consistent with the authority and responsibilities described in 38 U.S.C. § 312A.

Revise the Veterans Health Administration directive on minor construction projects to incorporate 38 U.S.C. § 312A requirements and develop a review process for confirming compliance with the Office of Construction and Facilities Management’s guidance and any applicable industry standards.

Review the Audie L. Murphy emergency department exam and fast-track rooms for compliance with applicable design and equipment standards and provide any recommendations to the executive director of the South Texas Veterans Health Care System.

Review an assessment by the Office of Construction and Facilities Management of the Audie L. Murphy’s emergency department for compliance with design and equipment requirements to determine what changes, if any, are necessary and take appropriate corrective action.

The facility Director ensures staff review primary care panel sizes and capacity levels to ensure they are accurate.

Reassess and clarify physical inventory requirements for equipment in medical facilities to ensure they are consistent with and meet the intent of VA Directive 7002.

Ensure that facility directors require custodial officers to regularly review nonexpendable inventory to determine whether the equipment is required and take appropriate action.

Ensure medical facility directors review inventory list compliance data to identify noncompliant services and implement a process to resolve noncompliance.

Ensure the Veterans Health Administration’s Procurement and Logistics Office, in coordination with VA’s Office of Acquisition and Logistics, regularly monitors inventory compliance data to identify and communicate with noncompliant facilities to proactively address delinquent inventories.

Require medical facilities to use a standardized report of survey dashboard to centrally report all lost, stolen, or damaged items.

Require medical facility directors to review inventory compliance and establish a process to ensure noncompliant equipment—to include equipment identified in this audit—is reported as lost, stolen, or damaged within required time frames.

Reiterate through formal communication that facilities and regional Veterans Integrated Service Networks are required to fully implement and use the Strategic Equipment Planning Guide and Enterprise Equipment Request process for equipment planning and approval and develop a system to monitor compliance and verifying facilities are using the process as required.

Ensure relevant staff complete training on the Strategic Equipment Planning Guide and Enterprise Equipment Request process that explains user roles and responsibilities.

Ensure facilities define and assign Strategic Equipment Planning Guide and Enterprise Equipment Request user roles and responsibilities as applicable.

Reiterate through the formal communication advised in recommendation 1 that the Strategic Equipment Planning Guide and Enterprise Equipment Request process are required for all equipment planning and approval—and clearly define whether there are any exceptions.

Specify when and which equipment purchases require review and approval by additional subject matter experts.

Ensure a disability compensation examiner who has completed PACT Act training provides an independent assessment and medical opinion for the 29 VHA and five VBA nonpresumptive PACT Act opinions identified by the Office of Inspector General that were provided before completing PACT Act training, and readjudicate the claims as needed.

Establish and use agreements with other VA medical facilities to help identify and schedule direct care when services are unavailable at a veteran’s local VA facility.

At least annually, emphasize to schedulers the proper methods (including the use of codes) to document when veterans opt out of community care.

Require the medical facility director at the Jesse Brown VA Medical Center in Chicago to make sure veterans who request mental health services are assessed for community care and informed of all potential care options.

Require medical facility directors in Veterans Integrated Service Network 12 to review and process consults initiated in the first quarter of fiscal year 2024 that remain in a pending, active, or scheduled status.

The principal executive director of the Office of Acquisition, Logistics, and Construction considers whether any additional training or other measures are necessary with respect to reporting the wrongdoing of a supervisor and the acceptance of free meals and drinks by VA employees during the February 2023 site visit.

The principal executive director of the Office of Acquisition, Logistics, and Construction determines whether any additional guidance, training, or oversight is needed with respect to ensuring VA employees do not improperly solicit sponsorships for VA events that do not primarily benefit veterans.

VA’s designated agency ethics official determines whether any additional steps need to be taken in connection with Ms. Dawson’s 2023 public financial disclosure based on the findings of this report.

Facility leaders identify barriers to providers completing toxic exposure screenings and implement actions to ensure providers complete screenings within 30 days of initiation.

Facility leaders ensure each service has a service-level workflow for test result communication that is consistent with VHA requirements.

The Director ensures the Chief of Staff attends Peer Review Committee meetings.

The Overton Brooks VA Medical Center Director conducts a comprehensive review of the patient’s hospitalization and takes action as indicated, including quality management improvement processes such as a peer review.

The Overton Brooks VA Medical Center Director ensures medical staff recognize the importance of obtaining hospitalized patients’ non-VA medical records and assesses the current processes for obtaining non-VA medical records, identifies any barriers to completion, and takes action as warranted.

The Overton Brooks VA Medical Center Director assesses the application of the one-to-one observation policy and practices at the facility, and takes action as warranted.

The Overton Brooks VA Medical Center Director reviews interim behavioral patient record flag processes to ensure implementation of safety strategies for staff and patients, and takes action as warranted.

The Overton Brooks VA Medical Center Director evaluates whether documentation of patient and patient-related behavioral events are reflected accurately in the electronic health record to facilitate continuity of care and communication among medical staff and takes action as necessary.

Confirm that medical facility directors develop local guidance on using automated dispensing cabinets in accordance with VHA Directive 1108.21 (and any revisions to this directive) and that facilities comply with that local guidance.

Require Pharmacy Benefits Management Services to revise VHA Directive 1108.21 to include routine monitoring for the use of generic information as a requirement in facility-level guidance for automated dispensing cabinets.

Ensure, in coordination with the controlled substance coordinator, or appropriate designee, and Veterans Integrated Service Networks, that reports detailing cabinet transactions for controlled substances removed using generic information are reviewed as part of required controlled substance inspections.

The Under Secretary for Health ensures the establishment of Veterans Integrated Service Network-level multidisciplinary cancer committees.

The Under Secretary for Health ensures Veterans Integrated Service Network staff submit an inventory of available oncology services and facility points of contact to the National Oncology Program Office annually.

The Under Secretary for Health ensures complexity level 1 and 2 facilities pursue membership in the National Cancer Institute’s National Clinical Trial Network or the National Cancer Institute Community Oncology Research Program.

The Under Secretary for Health ensures the establishment of facility-level multidisciplinary cancer committees, or partnering with another facility or Veterans Integrated Service Network to provide the required committee functions.

The Under Secretary for Health reviews the operations of oncology-related program offices to ensure the required oversight of Veterans Integrated Service Network and facility oncology program implementation.

Evaluate whether VA should establish an enterprise-wide governance structure for Caseflow development, consistent with VA’s initial comprehensive plan to Congress.

Develop a well-defined roadmap for the future development and implementation of Caseflow.

Enforce contract requirements through improved oversight, ensuring violations are identified and remediated.